Drinking Patterns in US Counties From 2002 to 2012

The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States

Introduction

Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state.

Objective

To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Design and Setting

A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year.

Main Outcomes and Measures

Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed.

Results

Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).

Conclusions and Relevance

There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

Genetic and Epigenetic Profile of Patients With Alcoholic Liver Disease

Alcoholic liver disease (ALD) is a definition encompassing a spectrum of disorders ranging from simple steatosis to cirrhosis and hepatocellular carcinoma. Excessive alcohol consumption triggers a series of metabolic reactions that affect the liver by inducing lipogenesis, increasing oxidative stress, and causing abnormal inflammatory responses. The metabolic pathways regulating lipids, reactive oxygen species (ROS), and immune system are closely related and in some cases cross-regulate each other. Therefore, it must be taken into account that major genetic and epigenetic abnormalities affecting enzymes involved in one of such pathways can play a pivotal role in ALD pathogenesis. However, recent studies have pointed out how a significant predisposition can also be determined by minor variants, such as relatively common polymorphisms, epigenetic modifications, and microRNA abnormalities. Genetic and epigenetic factors can also affect the progression of liver diseases, promoting fibrogenesis, cirrhosis, and ultimately hepatocellular carcinoma. It is noteworthy that some of these factors, such as some of the cytokines involved in the abnormal inflammatory responses, are shared with non-alcoholic liver disease, while other factors are unique to ALD. The study of the genetic and epigenetic components involved in the liver damages caused by alcohol is crucial to identify individuals with high risk of developing ALD, design personalized protocols for prevention and/or treatment, and select the best molecular targets for new therapies.

Pre-implantation alcohol exposure and developmental programming of FASD: an epigenetic perspective

Exposure to alcohol during in-utero development can permanently change the developmental programming of physiological responses, thereby increasing the risk of neurological illnesses during childhood and later adverse health outcomes associated with fetal alcohol spectrum disorder (FASD). There is an increasing body of evidence indicating that exposure to alcohol during gestation triggers lasting epigenetic alterations in offspring, long after the initial insult; together, these studies support the role of epigenetics in FASD etiology. However, we still have little information about how ethanol interferes with the fundamental epigenetic reprogramming wave (e.g., erasure and re-establishment of DNA methylation marks) that characterizes pre-implantation embryo development. This review examines key epigenetic processes that occur during pre-implantation development and especially focus on the current knowledge regarding how prenatal exposure to alcohol during this period could affect the developmental programming of the early stage pre-implantation embryo. We will also outline the current limitations of studies examining the in-vivo and in-vitro effects of alcohol exposure on embryos and underline the next critical steps to be taken if we want to better understand the implicated mechanisms to strengthen the translational potential for epigenetic markers for non-invasive early detection, and the treatment of newborns that have higher risk of developing FASD.

Trends and Patterns of Differences in Infectious Disease Mortality Among US Counties, 1980-2014

IMPORTANCE

Infectious diseases are mostly preventable but still pose a public health threat in the United States, where estimates of infectious diseases mortality are not available at the county level.

OBJECTIVE

To estimate age-standardized mortality rates and trends by county from 1980 to 2014 from lower respiratory infections, diarrheal diseases, HIV/AIDS, meningitis, hepatitis, and tuberculosis.

DESIGN AND SETTING

This study used deidentified death records from the National Center for Health Statistics (NCHS) and population counts from the US Census Bureau, NCHS, and the Human Mortality Database. Validated small-area estimation models were applied to these data to estimate county-level infectious disease mortality rates.

EXPOSURES

County of residence.

MAIN OUTCOMES AND MEASURES

Age-standardized mortality rates of lower respiratory infections, diarrheal diseases, HIV/AIDS, meningitis, hepatitis, and tuberculosis by county, year, and sex.

RESULTS

Between 1980 and 2014, there were 4 081 546 deaths due to infectious diseases recorded in the United States. In 2014, a total of 113 650 (95% uncertainty interval [UI], 108 764-117 942) deaths or a rate of 34.10 (95% UI, 32.63-35.38) deaths per 100 000 persons were due to infectious diseases in the United States compared to a total of 72 220 (95% UI, 69 887-74 712) deaths or a rate of 41.95 (95% UI, 40.52-43.42) deaths per 100 000 persons in 1980, an overall decrease of 18.73% (95% UI, 14.95%-23.33%). Lower respiratory infections were the leading cause of infectious diseases mortality in 2014 accounting for 26.87 (95% UI, 25.79-28.05) deaths per 100 000 persons (78.80% of total infectious diseases deaths). There were substantial differences among counties in death rates from all infectious diseases. Lower respiratory infection had the largest absolute mortality inequality among counties (difference between the 10th and 90th percentile of the distribution, 24.5 deaths per 100 000 persons). However, HIV/AIDS had the highest relative mortality inequality between counties (10.0 as the ratio of mortality rate in the 90th and 10th percentile of the distribution). Mortality from meningitis and tuberculosis decreased over the study period in all US counties. However, diarrheal diseases were the only cause of infectious diseases mortality to increase from 2000 to 2014, reaching a rate of 2.41 (95% UI, 0.86-2.67) deaths per 100 000 persons, with many counties of high mortality extending from Missouri to the northeastern region of the United States.

CONCLUSIONS AND RELEVANCE

Between 1980 and 2014, there were declines in mortality from most categories of infectious diseases, with large differences among US counties. However, over this time there was an increase in mortality for diarrheal diseases.

Circadian Mechanisms in Alcohol Use Disorder and Tissue Injury

Heavy use of alcohol can lead to addictive behaviors and to eventual alcohol-related tissue damage. While increased consumption of alcohol has been attributed to various factors including level of alcohol exposure and environmental factors such as stress, data from behavioral scientists and physiological researchers are revealing roles for the circadian rhythm in mediating the development of behaviors associated with alcohol use disorder as well as the tissue damage that drives physiological disease. In this work, we compile recent work on the complex mutually influential relationship that exists between the core circadian rhythm and the pharmacodynamics of alcohol. As we do so, we highlight implications of the relationship between alcohol and common circadian mechanisms of effected organs on alcohol consumption, metabolism, toxicity, and pathology.

Declining Health-Related Quality of Life in the U.S

INTRODUCTION

Despite recent declining mortality of the U.S. population from most leading causes, uncertainty exists over trends in health-related quality of life.

METHODS

The 2001-2002 and 2012-2013 National Epidemiologic Surveys on Alcohol and Related Conditions U.S. representative household surveys were analyzed for trends in health-related quality of life (n=79,402). Health-related quality of life was measured with the Short Form-6 Dimension scale derived from the Short Form-12. Changes in mean Short Form-6 Dimension ratings were attributed to changes in economic, social, substance abuse, mental, and medical risk factors.

RESULTS

Mean Short Form-6 Dimension ratings decreased from 0.820 (2001-2002) to 0.790 (2012-2013; p<0.0001). In regressions adjusted for age, sex, race/ethnicity, and education, variable proportions of this decline were attributable to medical (21.9%; obesity, cardiac disease, hypertension, arthritis, medical injury), economic (15.6%; financial crisis, job loss), substance use (15.3%; substance use disorder or marijuana use), mental health (13.1%; depression and anxiety disorders), and social (11.2%; partner, neighbor, or coworker problems) risks. In corresponding adjusted models, a larger percentage of the decline in Short Form-6 Dimension ratings of older adults (aged ≥55 years) was attributable to medical (35.3%) than substance use (7.4%) risk factors, whereas the reverse occurred for younger adults (aged 18-24 years; 5.7% and 19.7%) and adults aged 25-44 years (12.7% and 16.3%).

CONCLUSIONS

Between 2001-2002 and 2012-2013, there was a significant decline in average quality of life ratings of U.S. adults. The decline was partially attributed to increases in several modifiable risk factors, with medical disorders having a larger role than substance use disorders for older adults but the reverse for younger and middle-aged adults.

Binge ethanol exposure causes endoplasmic reticulum stress, oxidative stress and tissue injury in the pancreas

Alcohol abuse is associated with both acute and chronic pancreatitis. Repeated episodes of acute pancreatitis or pancreatic injury may result in chronic pancreatitis. We investigated ethanol-induced pancreatic injury using a mouse model of binge ethanol exposure. Male C57BL/6 mice were exposed to ethanol intragastrically (5 g/kg, 25% ethanol w/v) daily for 10 days. Binge ethanol exposure caused pathological changes in pancreas demonstrated by tissue edema, acinar atrophy and moderate fibrosis. Ethanol caused both apoptotic and necrotic cell death which was demonstrated by the increase in active caspase-3, caspase-8, cleaved PARP, cleaved CK-18 and the secretion of high mobility group protein B1 (HMGB1). Ethanol altered the function of the pancreas which was indicated by altered levels of alpha-amylase, glucose and insulin. Ethanol exposure stimulated cell proliferation in the acini, suggesting an acinar regeneration. Ethanol caused pancreatic inflammation which was indicated by the induction of TNF-alpha, IL-1beta, IL-6, MCP-1 and CCR2, and the increase of CD68 positive macrophages in the pancreas. Ethanol-induced endoplasmic reticulum stress was demonstrated by a significant increase in ATF6, CHOP, and the phosphorylation of PERK and eiF-2alpha. In addition, ethanol increased protein oxidation, lipid peroxidation and the expression of iNOS, indicating oxidative stress. Therefore, this paradigm of binge ethanol exposure caused a spectrum of tissue injury and cellular stress to the pancreas, offering a good model to study alcoholic pancreatitis.

Prevalence of Bystander Intervention Opportunities and Behaviors Among U.S. Army Soldiers

The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.

The Harms That Drinkers Cause: Regional Variations Within Countries

AIMS

Multinational studies of drinking and the harms it may cause typically treat countries as homogeneous. Neglecting variation within countries may lead to inaccurate conclusions about drinking behavior, and particularly about harms drinking causes for people other than the drinkers. This study is the first to examine whether drinkers' self-reported harms to others from drinking vary regionally within multiple countries.

DESIGN SETTING AND PARTICIPANTS

Analyses draw on survey data from 12,356 drinkers in 46 regions (governmental subunits) within 10 countries, collected as part of the GENACIS project (Wilsnack et al., 2009).

MEASURES

Drinkers reported on eight harms they may have caused others in the past 12 months because of their drinking. The likelihood of reporting one or more of these eight harms was evaluated by multilevel modeling (respondents nested within regions nested within countries), estimating random effects of country and region and fixed effects of gender, age, and regional prevalence of drinking.

FINDINGS

Reports of causing one or more drinking-related harms to others differed significantly by gender and age (but not by regional prevalence of drinking), but also differed significantly by regions within countries.

CONCLUSIONS

National and multinational evaluations of adverse effects of drinking on persons other than the drinkers should give more attention to how those effects may vary regionally within countries.

Gender Differences in Binge Drinking

Just as binge drinking rates differ for men and women, the predictors and consequences of binge drinking vary by gender as well. This article examines these differences and how binge drinking definitions and research samples and methods may influence findings. It also describes the relationship between age and binge drinking among men and women, and how drinking culture and environment affect this relationship. It examines gender-specific trends in binge drinking, predictors of binge drinking for men and women, and binge drinking in the context of smoking. The article reviews current findings on gender differences in the health consequences of binge drinking, including morbidity and mortality, suicidality, cancer, cardiovascular disorders, liver disorders, and brain and neurocognitive implications. It also discusses gender differences in the behavioral and social consequences of binge drinking, including alcohol-impaired driving, sexual assault, and intimate partner violence, and includes implications for treatment and prevention.

Recent trends in liver transplantation for alcoholic liver disease in the United States

AIM

To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD).

METHODS

We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ² and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing).

RESULTS

Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11.

CONCLUSION

There has been a dramatic increase in the number of transplants for ALD starting in 2013.

Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013 and 2014

PROBLEM

Chronic diseases and conditions (e.g., heart diseases, stroke, arthritis, and diabetes) are the leading causes of morbidity and mortality in the United States. These conditions are costly to the U.S. economy, yet they are often preventable or controllable. Behavioral risk factors (e.g., excessive alcohol consumption, tobacco use, poor diet, frequent mental distress, and insufficient sleep) are linked to the leading causes of morbidity and mortality. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, obtaining routine physical checkups, and checking blood pressure and cholesterol levels) can reduce morbidity and mortality from chronic diseases and conditions. Monitoring the health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services at multilevel public health points (states, territories, and metropolitan and micropolitan statistical areas [MMSA]) can provide important information for development and evaluation of health intervention programs.

REPORTING PERIOD

2013 and 2014.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disability in the United States and participating territories. This is the first BRFSS report to include age-adjusted prevalence estimates. For 2013 and 2014, these age-adjusted prevalence estimates are presented for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and selected MMSA.

RESULTS

Age-adjusted prevalence estimates of health status indicators, health care access and preventive practices, health risk behaviors, chronic diseases and conditions, and cardiovascular conditions vary by state, territory, and MMSA. Each set of proportions presented refers to the range of age-adjusted prevalence estimates of selected BRFSS measures as reported by survey respondents. The following are estimates for 2013. Adults reporting frequent mental distress: 7.7%-15.2% in states and territories and 6.3%-19.4% in MMSA. Adults with inadequate sleep: 27.6%-49.2% in states and territories and 26.5%-44.4% in MMSA. Adults aged 18-64 years having health care coverage: 66.9%-92.4% in states and territories and 60.5%-97.6% in MMSA. Adults identifying as current cigarette smokers: 10.1%-28.8% in states and territories and 6.1%-33.6% in MMSA. Adults reporting binge drinking during the past month: 10.5%-25.2% in states and territories and 7.2%-25.3% in MMSA. Adults with obesity: 21.0%-35.2% in states and territories and 12.1%-37.1% in MMSA. Adults aged ≥45 years with some form of arthritis: 30.6%-51.0% in states and territories and 27.6%-52.4% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 7.4%-17.5% in states and territories and 6.2%-20.9% in MMSA. Adults aged ≥45 years who have had a stroke: 3.1%-7.5% in states and territories and 2.3%-9.4% in MMSA. Adults with high blood pressure: 25.2%-40.1% in states and territories and 22.2%-42.2% in MMSA. Adults with high blood cholesterol: 28.8%-38.4% in states and territories and 26.3%-39.6% in MMSA. The following are estimates for 2014. Adults reporting frequent physical distress: 7.8%-16.0% in states and territories and 6.2%-18.5% in MMSA. Women aged 21-65 years who had a Papanicolaou test during the past 3 years: 67.7%-87.8% in states and territories and 68.0%-94.3% in MMSA. Adults aged 50-75 years who received colorectal cancer screening on the basis of the 2008 U.S. Preventive Services Task Force recommendation: 42.8%-76.7% in states and territories and 49.1%-79.6% in MMSA. Adults with inadequate sleep: 28.4%-48.6% in states and territories and 25.4%-45.3% in MMSA. Adults reporting binge drinking during the past month: 10.7%-25.1% in states and territories and 6.7%-26.3% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 8.0%-17.1% in states and territories and 7.6%-19.2% in MMSA. Adults aged ≥45 years with some form of arthritis: 31.2%-54.7% in states and territories and 28.4%-54.7% in MMSA. Adults with obesity: 21.0%-35.9% in states and territories and 19.7%-42.5% in MMSA.

INTERPRETATION

Prevalence of certain chronic diseases and conditions, health risk behaviors, and use of preventive health services varies among states, territories, and MMSA. The findings of this report highlight the need for continued monitoring of health status, health care access, health behaviors, and chronic diseases and conditions at state and local levels.

PUBLIC HEALTH ACTION

State and local health departments and agencies can continue to use BRFSS data to identify populations at risk for certain unhealthy behaviors and chronic diseases and conditions. Data also can be used to design, monitor, and evaluate public health programs at state and local levels.

Lifetime Alcohol Intake, Binge Drinking Behaviors, and Breast Cancer Risk

The prevalence of binge drinking in the United States is rising. While alcohol is a risk factor for breast cancer, less is known about the impact of episodic heavy drinking. In 2003-2009, women aged 35-74 years who were free of breast cancer were enrolled in the Sister Study (n = 50,884). Residents of the United States or Puerto Rico who had a sister with breast cancer were eligible. Multivariable Cox regression was used to estimate adjusted hazard ratios and 95% confidence intervals for breast cancer. During follow-up (mean = 6.4 years), 1,843 invasive breast cancers were diagnosed. Increased breast cancer risk was observed for higher lifetime alcohol intake (for ≥230 drinks/year vs. <60 drinks/year, hazard ratio (HR) = 1.35, 95% confidence interval (CI): 1.15, 1.58). Relative to low-level drinkers (<60 drinks/year), hazard ratios were increased for ever binge drinking (HR = 1.29, 95% CI: 1.15, 1.45) or blacking out (HR = 1.39, 95% CI: 1.17, 1.64). Compared with low-level drinkers who never binged, moderate drinkers (60-229 drinks/year) who binged had a higher risk (HR = 1.25, 95% CI: 1.08, 1.44). There was evidence of effect modification between moderate lifetime drinking and binging (relative excess risk due to interaction = 0.33, 95% CI: 0.10, 0.57). Our findings support the established association between lifetime alcohol intake and breast cancer and provide evidence for an increased risk associated with heavy episodic drinking, especially among moderate lifetime drinkers.

Ambient ultraviolet radiation exposure and hepatocellular carcinoma incidence in the United States

BACKGROUND

Hepatocellular carcinoma (HCC), the most commonly occurring type of primary liver cancer, has been increasing in incidence worldwide. Vitamin D, acquired from sunlight exposure, diet, and dietary supplements, has been hypothesized to impact hepatocarcinogenesis. However, previous epidemiologic studies examining the associations between dietary and serum vitamin D reported mixed results. The purpose of this study was to examine the association between ambient ultraviolet (UV) radiation exposure and HCC risk in the U.S.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database provided information on HCC cases diagnosed between 2000 and 2014 from 16 population-based cancer registries across the U.S. Ambient UV exposure was estimated by linking the SEER county with a spatiotemporal UV exposure model using a geographic information system. Poisson regression with robust variance estimation was used to calculate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association between ambient UV exposure per interquartile range (IQR) increase (32.4 mW/m2) and HCC risk adjusting for age at diagnosis, sex, race, year of diagnosis, SEER registry, and county-level information on prevalence of health conditions, lifestyle, socioeconomic, and environmental factors.

RESULTS

Higher levels of ambient UV exposure were associated with statistically significant lower HCC risk (n = 56,245 cases; adjusted IRR per IQR increase: 0.83, 95% CI 0.77, 0.90; p < 0.01). A statistically significant inverse association between ambient UV and HCC risk was observed among males (p for interaction = 0.01) and whites (p for interaction = 0.01).

CONCLUSIONS

Higher ambient UV exposure was associated with a decreased risk of HCC in the U.S. UV exposure may be a potential modifiable risk factor for HCC that should be explored in future research.

Sex differences in hippocampal damage, cognitive impairment, and trophic factor expression in an animal model of an alcohol use disorder

Compared to men, women disproportionally experience alcohol-related organ damage, including brain damage, and while men remain more likely to drink and to drink heavily, there is cause for concern because women are beginning to narrow the gender gap in alcohol use disorders. The hippocampus is a brain region that is particularly vulnerable to alcohol damage, due to cell loss and decreased neurogenesis. In the present study, we examined sex differences in hippocampal damage following binge alcohol. Consistent with our prior findings, we found a significant binge-induced decrement in dentate gyrus (DG) granule neurons in the female DG. However, in the present study, we found no significant decrement in granule neurons in the male DG. We show that the decrease in granule neurons in females is associated with both spatial navigation impairments and decreased expression of trophic support molecules. Finally, we show that post-binge exercise is associated with an increase in trophic support and repopulation of the granule neuron layer in the female hippocampus. We conclude that sex differences in alcohol-induced hippocampal damage are due in part to a paucity of trophic support and plasticity-related signaling in females.

Alcohol and fertility: how much is too much?

Alcohol use is prevalent in the United States. Given that a substantial portion of the drinking population is of reproductive age, it is not uncommon for couples who are attempting conception, or for women who are already pregnant, to be regularly consuming alcohol. Alcohol use is associated with multiple reproductive risks, including having a child with a Fetal Alcohol Spectrum Disorder, increased risk of fetal loss, and decreased chance of live birth. This review serves to examine the risks of alcohol in the context of reproductive health.

Identifying in-patient costs attributable to the clinical sequelae and comorbidities of alcoholic liver disease in a national hospital database

BACKGROUND AND AIMS

The clinical sequelae and comorbidities of alcoholic liver disease (ALD) often require hospitalization. The aims of this study were to (1) compare the average costs of hospitalizations with ALD and the costs of hospitalizations with other alcohol-related diagnoses that do not involve the liver; and (2) estimate the percentage of the difference in costs between the ALD and non-ALD hospitalizations that may be attributed to ascites, protein-calorie malnutrition and other conditions.

DESIGN

The 2012 National Inpatient Sample is a population-based cross-sectional database representing more than 94% of all discharges from community hospitals in the United States.

SETTING

Community hospitals in the United States.

PARTICIPANTS

The sample included 72 531 hospitalizations with ALD and 287 047 hospitalizations with other alcohol-related diagnoses.

MEASUREMENTS

The dependent variable was total in-patient costs. We estimated the contribution of ascites, protein-calorie malnutrition and other conditions to the difference in costs between patients with ALD and patients with other diagnoses.

FINDINGS

Average costs for ALD patients were $3188.4 higher than those for patients with other diagnoses ($13 543 versus $10 355; P < 0.001). Among all conditions in the analysis, protein-calorie malnutrition had the largest impact on costs [$6501; 95% confidence interval (CI) = 5956, 7045; P < 0.001] accounting for 12% of the higher costs of ALD stays.

CONCLUSIONS

Costs of hospital care for patients with alcoholic liver disease are higher than those for patients with other alcohol-related diagnoses. These increased costs are associated with specific clinical sequelae and comorbidities, with protein-calorie malnutrition-a largely preventable condition-making a substantial contribution.

Associations between Environmental Quality and Mortality in the Contiguous United States, 2000-2005

BACKGROUND

Assessing cumulative effects of the multiple environmental factors influencing mortality remains a challenging task.

OBJECTIVES

This study aimed to examine the associations between cumulative environmental quality and all-cause and leading cause-specific (heart disease, cancer, and stroke) mortality rates.

METHODS

We used the overall Environmental Quality Index (EQI) and its five domain indices (air, water, land, built, and sociodemographic) to represent environmental exposure. Associations between the EQI and mortality rates (CDC WONDER) for counties in the contiguous United States (n = 3,109) were investigated using multiple linear regression models and random intercept and random slope hierarchical models. Urbanicity, climate, and a combination of the two were used to explore the spatial patterns in the associations.

RESULTS

We found 1 standard deviation increase in the overall EQI (worse environment) was associated with a mean 3.22% (95% CI: 2.80%, 3.64%) increase in all-cause mortality, a 0.54% (95% CI: -0.17%, 1.25%) increase in heart disease mortality, a 2.71% (95% CI: 2.21%, 3.22%) increase in cancer mortality, and a 2.25% (95% CI: 1.11%, 3.39%) increase in stroke mortality. Among the environmental domains, the associations ranged from -1.27% (95% CI: -1.70%, -0.84%) to 3.37% (95% CI: 2.90%, 3.84%) for all-cause mortality, -2.62% (95% CI: -3.52%, -1.73%) to 4.50% (95% CI: 3.73%, 5.27%) for heart disease mortality, -0.88% (95% CI: -2.12%, 0.36%) to 3.72% (95% CI: 2.38%, 5.06%) for stroke mortality, and -0.68% (95% CI: -1.19%, -0.18%) to 3.01% (95% CI: 2.46%, 3.56%) for cancer mortality. Air had the largest associations with all-cause, heart disease, and cancer mortality, whereas the sociodemographic index had the largest association with stroke mortality. Across the urbanicity gradient, no consistent trend was found. Across climate regions, the associations ranged from 2.29% (95% CI: 1.87%, 2.72%) to 5.30% (95% CI: 4.30%, 6.30%) for overall EQI, and larger associations were generally found in dry areas for both overall EQI and domain indices.

CONCLUSIONS

These results suggest that poor environmental quality, particularly poor air quality, was associated with increased mortality and that associations vary by urbanicity and climate region. Citation: Jian Y, Messer LC, Jagai JS, Rappazzo KM, Gray CL, Grabich SC, Lobdell DT. 2017. Associations between environmental quality and mortality in the contiguous United States, 2000-2005. Environ Health Perspect 125:355-362; http://dx.doi.org/10.1289/EHP119.

Trends and Patterns of Disparities in Cancer Mortality Among US Counties, 1980-2014

Introduction

Cancer is a leading cause of morbidity and mortality in the United States and results in a high economic burden.

Objective

To estimate age-standardized mortality rates by US county from 29 cancers.

Design and Setting

Deidentified death records from the National Center for Health Statistics (NCHS) and population counts from the Census Bureau, the NCHS, and the Human Mortality Database from 1980 to 2014 were used. Validated small area estimation models were used to estimate county-level mortality rates from 29 cancers: lip and oral cavity; nasopharynx; other pharynx; esophageal; stomach; colon and rectum; liver; gallbladder and biliary; pancreatic; larynx; tracheal, bronchus, and lung; malignant skin melanoma; nonmelanoma skin cancer; breast; cervical; uterine; ovarian; prostate; testicular; kidney; bladder; brain and nervous system; thyroid; mesothelioma; Hodgkin lymphoma; non-Hodgkin lymphoma; multiple myeloma; leukemia; and all other cancers combined.

Exposure

County of residence.

Main Outcomes and Measures

Age-standardized cancer mortality rates by county, year, sex, and cancer type.

Results

A total of 19 511 910 cancer deaths were recorded in the United States between 1980 and 2014, including 5 656 423 due to tracheal, bronchus, and lung cancer; 2 484 476 due to colon and rectum cancer; 1 573 593 due to breast cancer; 1 077 030 due to prostate cancer; 1 157 878 due to pancreatic cancer; 209 314 due to uterine cancer; 421 628 due to kidney cancer; 487 518 due to liver cancer; 13 927 due to testicular cancer; and 829 396 due to non-Hodgkin lymphoma. Cancer mortality decreased by 20.1% (95% uncertainty interval [UI], 18.2%-21.4%) between 1980 and 2014, from 240.2 (95% UI, 235.8-244.1) to 192.0 (95% UI, 188.6-197.7) deaths per 100 000 population. There were large differences in the mortality rate among counties throughout the period: in 1980, cancer mortality ranged from 130.6 (95% UI, 114.7-146.0) per 100 000 population in Summit County, Colorado, to 386.9 (95% UI, 330.5-450.7) in North Slope Borough, Alaska, and in 2014 from 70.7 (95% UI, 63.2-79.0) in Summit County, Colorado, to 503.1 (95% UI, 464.9-545.4) in Union County, Florida. For many cancers, there were distinct clusters of counties with especially high mortality. The location of these clusters varied by type of cancer and were spread in different regions of the United States. Clusters of breast cancer were present in the southern belt and along the Mississippi River, while liver cancer was high along the Texas-Mexico border, and clusters of kidney cancer were observed in North and South Dakota and counties in West Virginia, Ohio, Indiana, Louisiana, Oklahoma, Texas, Alaska, and Illinois.

Conclusions and Relevance

Cancer mortality declined overall in the United States between 1980 and 2014. Over this same period, there were important changes in trends, patterns, and differences in cancer mortality among US counties. These patterns may inform further research into improving prevention and treatment.

Health and Social Conditions of the Poorest Versus Wealthiest Counties in the United States

OBJECTIVES

To more clearly articulate, and more graphically demonstrate, the impact of poverty on various health outcomes and social conditions by comparing the poorest counties to the richest counties in the United States and to other countries in the world.

METHODS

We used 5-year averages for median household income to form the 3141 US counties into 50 new "states"-each representing 2% of the counties in the United States (62 or 63 counties each). We compared the poorest and wealthiest "states."

RESULTS

We documented dramatic and statistically significant differences in life expectancy, smoking rates, obesity rates, and almost every other measure of health and well-being between the wealthiest and poorest "states" in the country. The populations of more than half the countries in the world have a longer life expectancy than do US persons living in the poorest "state."

CONCLUSIONS

This analysis graphically demonstrates the true impact of the extreme socioeconomic disparities that exist in the United States. These differences can be obscured when one looks only at state data, and suggest that practitioners and policymakers should increasingly focus interventions to address the needs of the poorest citizens in the United States.

Age moderates the association of depressive symptoms and unhealthy alcohol use in the National Guard

Unhealthy drinking is a significant problem contributing to poor health and performance of military personnel. The Iowa Army National Guard and the Iowa Department of Public Health have collaborated with the Substance Abuse and Mental Health Administration to better identify unhealthy substance use via Screening, Brief Intervention, and Referral to Treatment program (SBIRT). Yet, little research has been conducted on the Guard's use of SBIRT. This study examined depression, age, deployment status, and sex as factors contributing to unhealthy drinking. Of the Guardsmen who took part in SBIRT, 3.7% (n=75) met the criteria for unhealthy drinking and 3.9% (n=78) had some level of depression. The overall multivariate model significantly predicted unhealthy drinking (χ(2)(5)=41.41, p<0.001) with age moderating the association of depressive symptoms and unhealthy alcohol (Wald χ(2)(1)=7.16, p=0.007). These findings add to the existing understanding of factors contributing to unhealthy drinking suggesting the association between the presence of depression and unhealthy drinking depends on age of the Guradsman. This age and depression interaction may be an important diagnostic feature to consider for unhealthy drinking in the Guard. Furthermore, previous research on the general military population finds similar percentages, providing support for SBIRT as an effective screening tool in the Guard.

Alcohol, cigarette smoking, and ovarian reserve in reproductive-age African-American women

BACKGROUND

Although alcohol consumption and cigarette smoking are common behaviors in reproductive-age women, little is known about the impact of consumption patterns on ovarian reserve. Even less is known about the effects of smoking and alcohol use in reproductive-age African-American women.

OBJECTIVE

The objective of the study was to examine the impact of the patterns of alcohol intake and cigarette smoking on anti-Müllerian hormone levels as a marker of ovarian reserve in African-American women.

STUDY DESIGN

This was a cross-sectional analysis from the baseline clinical visit and data collection of the Study of Environment, Lifestyle, and Fibroids performed by the National Institute of Environmental Health Sciences. A total of 1654 volunteers, aged 23-34 years, recruited from the Detroit, Michigan community completed questionnaires on alcohol intake and cigarette smoking and provided serum for anti-Müllerian hormone measurement. Multivariable linear and logistic regressions were used as appropriate to estimate the effect of a range of exposure patterns on anti-Müllerian hormone levels while adjusting for potential confounders including age, body mass index, and hormonal contraception.

RESULTS

Most participants were alcohol drinkers (74%). Of those, the majority (74%) engaged in binge drinking at least once in the last year. Women who reported binge drinking twice weekly or more had 26% lower anti-Müllerian hormone levels compared with current drinkers who never binged (95% confidence interval, -44, -2, P < .04). Other alcohol consumption patterns (both past and current) were unrelated to anti-Müllerian hormone. The minority of participants currently (19%) or formerly (7%) smoked, and only 4% of current smokers used a pack a day or more. Neither smoking status nor second-hand smoke exposure in utero, childhood, or adulthood was associated with anti-Müllerian hormone levels.

CONCLUSION

Results suggest that current, frequent binge drinking may have an adverse impact on ovarian reserve. Other drinking and smoking exposures were not associated with anti-Müllerian hormone in this cohort of healthy, young, African-American women. A longitudinal study of how these common lifestyle behaviors have an impact on the variability in age-adjusted anti-Müllerian hormone levels is merited.

The prevalence of binge drinking among primary care residents

BACKGROUND

Over one quarter of American adults binge drink, resulting in significant alcohol-related morbidity and mortality. Although brief interventions can decrease patients' alcohol use, many physicians in training do not provide this service. This study examines the prevalence of binge drinking among primary care residents, and the association of resident drinking behaviors with addressing patients' hazardous alcohol use.

METHODS

Between July 2013 and August 2014, the authors surveyed all trainees in 6 primary care residency programs. The survey assessed self-reported frequency of binge drinking, confidence working with hazardous drinkers, and the performance of brief interventions when hazardous drinking was detected in patients.

RESULTS

221 of 246 residents completed the survey (response rate 89.8%). Half of residents (109/221) reported at least one episode of binge drinking in the prior year, and 18% (39/221) reported binge drinking at least once a month. In multivariable analysis, monthly binge drinking was associated with male gender (OR 2.5, 95% CI 1.1-5.4) and year of training (OR 0.25 for Year 3 vs. Year 1, 95% CI 0.07-0.90). Few residents felt confident they could help patients cut down or quit alcohol, regardless of personal binge drinking history (19% for those who binged monthly, 24% for those who binged 1-11 times a year, and 27% for those who never binged, p for trend = 0.31). Performance of brief interventions did not vary by personal binge drinking history.

CONCLUSIONS

Binge drinking is common among primary care residents. In addition to training residents to effectively intervene with hazardous drinkers, residency programs should address the high prevalence of binge drinking by their physicians in training.

Neighborhood Contextual Factors, Alcohol Use, and Alcohol Problems in the United States: Evidence From a Nationally Representative Study of Young Adults

BACKGROUND

There is considerable variation in alcohol use and problems across the United States, suggesting that systematic regional differences might contribute to alcohol involvement. Several neighborhood contextual factors may be important aspects of this "alcohol environment."

METHODS

Participants were 15,197 young adults (age 18 to 26) from Wave III of the National Longitudinal Study of Adolescent to Adult Health, a nationally representative U.S. survey. Measures of past-year alcohol use and problems were obtained via structured in-home interviews. Tract-level neighborhood contextual factors (density of on- and off-premises alcohol outlets, neighborhood disadvantage, rural vs. urban residence) were derived from census indicators and geocoded state-level alcohol outlet licenses. Multivariate logistic regression, ordered logistic regression, or negative binomial regression models, including age, sex, race, and household income as covariates, were fit to examine the relation of the neighborhood contextual factors with alcohol use and problems.

RESULTS

The most consistent finding across 4 of the 5 measures of alcohol involvement was their association with neighborhood advantage; the active ingredient underlying this effect was primarily the proportion of educated residents in the neighborhood. The densities of alcohol outlets were associated with any alcohol use-they were not associated with binge drinking or alcohol problems, nor could they explain any of the neighborhood advantage effects. The influence of alcohol outlet densities on alcohol involvement did not differ for those above or below the legal age to purchase alcohol. Living in a rural versus an urban neighborhood was associated with a different alcohol use pattern characterized by a lower likelihood of any drinking, but among those who drank, consuming more alcohol per occasion.

CONCLUSIONS

Living in a more advantaged and educated urban neighborhood with greater densities of bars and restaurants is associated with greater alcohol involvement among 18- to 26-year-olds in the United States.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Role of alcohol in the development and progression of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a significant cause of cancer-related morbidity and mortality. Chronic, heavy ethanol consumption is a major risk for developing the worsening liver pathologies that culminate in hepatic cirrhosis, the leading risk factor for developing HCC. A significant body of work reports the biochemical and pathological consequences of ethanol consumption and metabolism during hepatocarcinogeneis. The systemic effects of ethanol means organ system interactions are equally important in understanding the initiation and progression of HCC within the alcoholic liver. This review aims to summarize the effects of ethanol-ethanol metabolism during the pathogenesis of alcoholic liver disease, the progression toward HCC and the importance of ethanol as a comorbid factor for HCC development.

Recent Advances in Nicotinic Receptor Signaling in Alcohol Abuse and Alcoholism

Alcohol is the most commonly abused legal substance and alcoholism is a serious public health problem. It is a leading cause of preventable death in the world. The cellular and molecular mechanisms of alcohol reward and addiction are still not well understood. Emerging evidence indicates that unlike other drugs of abuse, such as nicotine, cocaine, or opioids, alcohol targets numerous channel proteins, receptor molecules, and signaling pathways in the brain. Previously, research has identified brain nicotinic acetylcholine receptors (nAChRs), a heterogeneous family of pentameric ligand-gated cation channels expressed in the mammalian brain, as critical molecular targets for alcohol abuse and dependence. Genetic variations encoding nAChR subunits have been shown to increase the vulnerability to develop alcohol dependence. Here, we review recent insights into the rewarding effects of alcohol, as they pertain to different nAChR subtypes, associated signaling molecules, and pathways that contribute to the molecular mechanisms of alcoholism and/or comorbid brain disorders. Understanding these cellular changes and molecular underpinnings may be useful for the advancement of brain nicotinic-cholinergic mechanisms, and will lead to a better translational and therapeutic outcome for alcoholism and/or comorbid conditions.